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PURPOSE: Pneumonia is an important cause of mortality and morbidity in immunocompromised patients. Computed tomography (CT) is the most sensitive imaging modality for the diagnosis and surveillance of these patients. Since CT exposes the patient to ionizing radiation, we investigated the utility of magnetic resonance imaging (MRI) in the diagnosis and surveillance of immunocompromised patients with pneumonia.
METHODS: The study included 40 immunocompromised patients with pneumonia documented on CT. The patients were examined by MRI within 48 hours of CT examination. All images were obtained with three different sequences: balanced fast field echo, T1-weighted turbo spin-echo (TSE), and T2-weighted TSE. Lung abnormalities were evaluated using CT and MRI.
RESULTS: Infection was determined in 36 patients (90%), while the causative organism remained unknown in four patients (10%). In all the patients, the CT findings were consistent with infection, although three patients showed no abnormal findings on MRI. CT was superior to MRI in the detection of the tree-in-bud nodules, centrilobular nodules, and halo sign (P < 0.001, for all). A significant difference was observed between the MRI sequences and CT in terms of the number of detected nodules (P < 0.001). The nodule detection rate of MRI significantly increased in proportion to the size of the nodule (P < 0.001). All MRI sequences had almost perfect agreement with CT for the detection of consolidation (к=0.950, P < 0.001), patchy increased density (к=1, P < 0.001), pleural effusion (к=0.870, P < 0.001), pericardial effusion (к=1, P < 0.001), reverse halo sign, (к=1 P < 0.001), 10-20 mm, nodules (к=0.896, P < 0.001 for CT and B-FFE; к=0.948, P < 0.001 for CT and T1- or T2-weighted imaging) 10-20 mm, > 20 mm nodules (к=0.844, P < 0.001).
CONCLUSION: Although CT is superior to MRI in the diagnosis of pneumonia in immunocompromised patients, MRI is an important imaging modality that can be used, particularly in the follow-up of these patients, thus decreasing to avoid ionizing radiation exposure.

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AIMS: Coexistence of lung cancer and granulomatous inflammation in the same patient confuses clinicians. We aimed to document the prevalence, clinicopathological features, treatment outcomes and prognosis in patients with coexisting granulomatous inflammation undergoing curative lung resection for lung cancer, in a tuberculosis (TB)-endemic country.
METHODS: An observational cohort study of patients with lung cancer undergoing curative resection between 2012 and 2015 in a tertiary centre in Singapore.
RESULTS: One hundred and twenty-seven patients underwent lung resection for cancer, out of which 19 (14.9%) had coexistent granulomatous inflammation in the resected specimen. Median age was 68 years and 58.2% were males. Overall median (range) survival was 451 (22-2452) days. Eighteen (14%) patients died at median duration of 271 days after surgery. The postsurgery median survival for those alive was 494 (29-2452) days in the whole group. Subgroup analysis did not reveal any differences in age, gender, location of cancer, radiological features, type of cancer, chemotherapy, history of TB or survival in patients with or without coexistent granulomatous inflammation.
CONCLUSIONS: Incidental detection of granulomatous inflammation in patients undergoing lung resection for cancer, even in a TB-endemic country, may not require any intervention. Such findings may be due to either mycobacterial infection in the past or 'sarcoid reaction' to cancer. Although all patients should have their resected specimen sent for acid-fast bacilli culture and followed up until the culture results are reported, the initiation of the management of such patients as per existing lung cancer management guidelines does not affect their outcome adversely.

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Importance: Guidelines recommend against antibiotic use to treat asthma attacks. A study with telithromycin reported benefit, but adverse reactions limit its use.
Objective: To determine whether azithromycin added to standard care for asthma attacks in adults results in clinical benefit.
Design, Setting, and Participants: The Azithromycin Against Placebo in Exacerbations of Asthma (AZALEA) randomized, double-blind, placebo-controlled clinical trial, a United Kingdom-based multicenter study in adults requesting emergency care for acute asthma exacerbations, ran from September 2011 to April 2014. Adults with a history of asthma for more than 6 months were recruited within 48 hours of presentation to medical care with an acute deterioration in asthma control requiring a course of oral and/or systemic corticosteroids.
Interventions: Azithromycin 500 mg daily or matched placebo for 3 days.

Main Outcomes and Measures: The primary outcome was diary card symptom score 10 days after randomization, with a hypothesized treatment effect size of -0.3. Secondary outcomes were diary card symptom score, quality-of-life questionnaires, and lung function changes, all between exacerbation and day 10, and time to a 50% reduction in symptom score.

Results: Of 4582 patients screened at 31 centers, 199 of a planned 380 were randomized within 48 hours of presentation. The major reason for nonrecruitment was receipt of antibiotics (2044 [44.6%] screened patients). Median time from presentation to drug administration was 22 hours (interquartile range, 14-28 hours). Exacerbation characteristics were well balanced across treatment arms and centers. The primary outcome asthma symptom scores were mean (SD), 4.14 (1.38) at exacerbation and 2.09 (1.71) at 10 days for the azithromycin group and 4.18 (1.48) and 2.20 (1.51) for the placebo group, respectively. Using multilevel modeling, there was no significant difference in symptom scores between azithromycin and placebo at day 10 (difference, -0.166; 95% CI, -0.670 to 0.337), nor on any day between exacerbation and day 10. No significant between-group differences were observed in quality-of-life questionnaires or lung function between exacerbation and day 10, or in time to 50% reduction in symptom score.

Conclusions and Relevance: In this randomized population, azithromycin treatment resulted in no statistically or clinically significant benefit. For each patient randomized, more than 10 were excluded because they had already received antibiotics.
Trial Registration: clinicaltrials.gov Identifier: NCT01444469.

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BACKGROUND: Diagnostic evaluation of patients with diffuse parenchymal lung disease (DPLD) is best achieved by a multidisciplinary team correlating clinical, radiologic, and pathologic features. Surgical lung biopsies remain the gold standard for histopathologic diagnosis of idiopathic interstitial pneumonias. Emerging data suggest an increasing role for transbronchial cryobiopsy (TBC) in DPLD evaluation. We describe our experience with TBC in patients with DPLD.

METHODS: We retrospectively reviewed medical records of patients with radiographic features of DPLD who underwent TBC at Mayo Clinic, Rochester, Minnesota in June 2013-September 2015.
RESULTS: Seventy-four patients (33 female, 45%) with a mean age of 63 years (SD 13.8) were included. Mean maximal diameter of samples was 9.2 mm (range 2-20, SD 3.9). The median number of samples per procedure was 3 (range 1-7). Diagnostic yield was 51% (38/74). The most frequent histopathologic patterns were granulomatous inflammation (12) and organizing pneumonia (OP) (11), resulting in the final diagnoses of hypersensitivity pneumonitis (6), cryptogenic OP (6), connective tissue disease-associated OP (3), drug toxicity (3), infection-related OP (2), sarcoidosis (2), and aspiration (1). Other histopathologic patterns included respiratory bronchiolitis (3), acute fibrinous and organizing pneumonia (2), desquamative interstitial pneumonia (1), diffuse alveolar damage (1), pulmonary alveolar proteinosis (1), amyloidosis (1), eosinophilic pneumonia (1), necrotizing vasculitis (1), bronchiolitis with food particle (1), and malignancy (3). Pneumothorax developed in one patient (1.4%), bleeding occurred in 16 (22%).

CONCLUSIONS: Our single center cohort demonstrated 51% diagnostic yield from TBC; the rates of pneumothorax and bleeding were 1.4% and 22%, respectively. Optimal use of TBC needs to be determined.